Inside the ventilator question

Covid-19 is making us think about many things we have never had to consider before – one of them is the use of ventilators.

There is a lot of concern about how many intensive care beds and ventilators we have in New Zealand. Panic-inducing headlines from overseas has led to discussion about how they might be ‘rationed’ if we were to run out. However, we feel there is an urgent need for more information about what ventilators are and when and why they are used. Many of us might have never seen a ventilator, or understand when and why they are not used. This includes how these decisions are made and who makes them under ‘usual’ circumstances. This is vital to understanding the circumstances under which someone with Covid-19 would benefit from being ventilated.

What is a ventilator?

It was during the polio pandemics of the 20 century that the first ventilators were invented. They were commonly known as ‘the iron lung’. Today’s invasive mechanical ventilators look very different, but work to achieve the same result.

A ventilator (or respirator or breathing machine) is a machine that attaches to the patient by way of a tube placed in through the mouth to the windpipe. This machine helps support the person’s breathing and delivers air and/or oxygen to them. Doctors adjust the level of support and/or oxygen as necessary. In New Zealand, ventilated patients are cared for in an Intensive Care Unit. Being on a ventilator usually means being attached to lots of other tubes, drains and intravenous lines and monitoring machines. When someone is on a ventilator they require constant close monitoring and a lot of very (intensive) care from specially-trained health professionals – including doctors, nurses, physiotherapists and other allied health staff.

When are ventilators used?

Ventilators aid in the process of breathing when people cannot breathe normally. This may be after major surgery or when recovering from a critical illness or major trauma like a car accident. Once patients are sufficiently recovered and awake, the breathing tube and ventilator are removed. A ventilator takes over the body's breathing process when it is unable to do the job of breathing itself. The ventilator does not, however, treat the underlying problem or issue.

When are ventilators not used?

Ventilators do not treat the underlying cause for people not being able to breathe on their own. Therefore, if the underlying cause of not being able to breathe cannot be treated, a ventilator is unlikely to provide any overall benefit. Indeed, ventilation in this case might cause more harm than good. For example, people who have lung failure because of advanced and progressive lung disease - such as advanced lung cancer, chronic obstructive airway disease (COPD) or pulmonary fibrosis – are unlikely to benefit from mechanical ventilation due to overall frailty, especially when they have several ongoing conditions like heart failure or kidney disease.

Ventilator use within the context of Covid-19

Doctors together with other team members make decisions about whether or not mechanical ventilation is appropriate for a person by weighing up the benefits and risks to someone’s health and wellbeing, like they do for all treatment. For people who have an underlying progressive and advanced medical condition, mechanical ventilation is unlikely to be of benefit. In these circumstances a ventilator would not help a person and so would not be offered. In the context of Covid-19, ventilation is not the right treatment for everyone. We are hearing about other countries where they have different healthcare systems – these countries may use ventilators differently from the way we do in New Zealand. For example, in the US due to the litigious environment, people often ask for and receive medical treatment even if it is likely to cause more harm than good. In New Zealand, this decision is made by the clinical team in close communication with the patient and family.

What do we know about the experience of being ventilated?

Ventilation is invasive and unpleasant. People on ventilators cannot drink, eat or talk. They are generally confined to an ICU bed and cannot easily shower or bathe. They may require medicine to help them relax, as the breathing tube is uncomfortable. If a person recovers from being ventilated that recovery, from being in ICU on a ventilator, can take months or even years. Currently in New Zealand, it is extremely rare for very frail people, those with multiple chronic illnesses or those in the end stages of severe disease to have mechanical ventilation. This is because it would cause harm and distress for the patient and their family and whānau. In fact a recent study carried out by our group in aged care showed that of the older people we studied, 93 percent of deaths were expected. Of those people, very few were cared for in hospital at the time of their death and almost none were cared for in intensive care units. This will be no different if someone is dying from pneumonia pre, during or post the Covid-19 crisis.

These people still need care that is very intensive even when they are approaching the very end of life. This kind of care is focused on preventing and relieving symptoms such as breathlessness and pain, optimising wellbeing and support for families and whānau as well as the person themselves. This kind of intensive care is called palliative care and is provided in hospital, home and aged residential care.

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